Abstract：
Multiple urological societies recommend chest imaging for suspicious renal masses using chest x-ray or CT as clinically indicated. The purpose of chest imaging is to assess for thoracic metastasis at the time of renal mass diagnosis. Ideally, imaging use and type are commensurate with risk related to tumor size and clinical stage. We examined current practice patterns with chest imaging compliance in the state of Michigan and implemented clinician education and value-based reimbursement incentivization on guideline adherence.
MUSIC (Michigan Urological Surgery Improvement Collaborative)-KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) is a statewide initiative focusing on quality improvement for patients with cT1 renal masses. Data regarding chest imaging in MUSIC and panel discussion occurred at an in-person MUSIC meeting in October 2019. Adherence to chest imaging guidelines was made a value-based reimbursement metric at the triannual MUSIC meeting in January 2020. Adherence was defined as optional in renal masses <3 cm (CT not indicated), recommended in renal masses 3-5 cm (chest x-ray preferred), and required in renal masses >5 cm (CT preferred). The MUSIC registry was queried for percentage of patients receiving chest imaging by type. Factors associated with adherence were assessed.
There was significant practice-level variation in chest imaging rates across the 14 contributing practices, ranging from 11% to 68%. Compliance with MUSIC guidelines for chest imaging during evaluation of T1 renal masses was 81.8% overall, with only 61.8% of patients with masses >5 cm meeting the guideline requiring imaging with preference for CT. Factors associated with increased adherence included larger tumor size (T1b vs T1a) and solid (vs cystic or indeterminate) tumor (P < .05 for each). Prior to value-based reimbursement introduction, 46.7% of patients underwent imaging of either type, compared to 49.0% post-intervention. Imaging rates only slightly increased in masses >5 cm (58.3% before value-based reimbursement vs 61.2% after, P = .56) and 3-5 cm (50.0% before value-based reimbursement vs 56.2% after, P = .0585).
Chest imaging guideline adherence during the initial evaluation of cT1 renal masses is acceptable, particularly given that most masses are <3 cm, for which metastatic risk is low. However, despite consensus from major urological societies regarding imaging for masses >4-5 cm, imaging rates were low across MUSIC. After educational and value-based reimbursement incentive initiation, rates of imaging for 3-5-cm and >5-cm masses changed only slightly. There remains significant practice variability and room for improvement.
MUSIC (Michigan Urological Surgery Improvement Collaborative)-KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) is a statewide initiative focusing on quality improvement for patients with cT1 renal masses. Data regarding chest imaging in MUSIC and panel discussion occurred at an in-person MUSIC meeting in October 2019. Adherence to chest imaging guidelines was made a value-based reimbursement metric at the triannual MUSIC meeting in January 2020. Adherence was defined as optional in renal masses <3 cm (CT not indicated), recommended in renal masses 3-5 cm (chest x-ray preferred), and required in renal masses >5 cm (CT preferred). The MUSIC registry was queried for percentage of patients receiving chest imaging by type. Factors associated with adherence were assessed.
There was significant practice-level variation in chest imaging rates across the 14 contributing practices, ranging from 11% to 68%. Compliance with MUSIC guidelines for chest imaging during evaluation of T1 renal masses was 81.8% overall, with only 61.8% of patients with masses >5 cm meeting the guideline requiring imaging with preference for CT. Factors associated with increased adherence included larger tumor size (T1b vs T1a) and solid (vs cystic or indeterminate) tumor (P < .05 for each). Prior to value-based reimbursement introduction, 46.7% of patients underwent imaging of either type, compared to 49.0% post-intervention. Imaging rates only slightly increased in masses >5 cm (58.3% before value-based reimbursement vs 61.2% after, P = .56) and 3-5 cm (50.0% before value-based reimbursement vs 56.2% after, P = .0585).
Chest imaging guideline adherence during the initial evaluation of cT1 renal masses is acceptable, particularly given that most masses are <3 cm, for which metastatic risk is low. However, despite consensus from major urological societies regarding imaging for masses >4-5 cm, imaging rates were low across MUSIC. After educational and value-based reimbursement incentive initiation, rates of imaging for 3-5-cm and >5-cm masses changed only slightly. There remains significant practice variability and room for improvement.
摘要：
背景：多个泌尿外科学会推荐使用胸部X线（CXR）对可疑肾脏肿块进行胸部成像，或临床指示的计算机断层扫描（CT）。胸部成像的目的是在诊断肾脏肿块（RM）时评估胸部转移。理想情况下,影像学使用和类型与肿瘤大小和临床分期相关的风险相称。我们检查了密歇根州胸部成像依从性的当前实践模式，并对指南依从性实施了临床医生教育和VBR（基于价值的报销）激励。
方法：MUSIC-KIDNEY是一项全州范围内的倡议，专注于cT1RM患者的质量改善。关于MUSIC胸部成像的数据和小组讨论发生在2019年10月的现场MUSIC会议上。在2020年1月举行的三年一次的MUSIC会议上，对胸部成像指南的遵守是VBR指标。在RM<3cm（CT未显示）中，依从性被定义为可选的，建议使用RM3-5厘米（首选CXR），且要求RM>5cm(CT优先)。根据类型查询MUSIC注册表中接受胸部成像的患者百分比。评估与依从性相关的因素。
结果：在14个有贡献的实践中，胸部成像率存在显著的实践水平差异，从11%到68%不等。T1RM评估期间符合MUSIC胸部成像指南的总体为81.8%，只有61.8％的肿块>5cm的患者符合指南，需要首选CT进行成像。与粘附性增加相关的因素包括较大的肿瘤大小（T1bvsT1a）和实体（与囊性或不确定）肿瘤（P<0.05）。在引入VBR之前，46.7％的患者接受了两种类型的影像学检查，相比之下，干预后为49.0%。在>5cm的肿块中，成像率仅略有增加（VBR前58.3％vs后61.2％，P=.56）和3-5厘米（VBR前50.0％vsVBR后56.2％，P=.0585）。
结论：在cT1肾脏肿块的初始评估期间，胸部成像指南的依从性是可以接受的，特别是考虑到大多数肿块<3cm，转移风险较低。然而,尽管主要泌尿外科学会对>4-5厘米的肿块成像达成了共识，整个音乐的成像率很低。在教育和VBR激励启动后，3-5厘米和>5厘米肿块的成像率仅略有变化。仍然存在显著的实践可变性和改进空间。
方法：MUSIC-KIDNEY是一项全州范围内的倡议，专注于cT1RM患者的质量改善。关于MUSIC胸部成像的数据和小组讨论发生在2019年10月的现场MUSIC会议上。在2020年1月举行的三年一次的MUSIC会议上，对胸部成像指南的遵守是VBR指标。在RM<3cm（CT未显示）中，依从性被定义为可选的，建议使用RM3-5厘米（首选CXR），且要求RM>5cm(CT优先)。根据类型查询MUSIC注册表中接受胸部成像的患者百分比。评估与依从性相关的因素。
结果：在14个有贡献的实践中，胸部成像率存在显著的实践水平差异，从11%到68%不等。T1RM评估期间符合MUSIC胸部成像指南的总体为81.8%，只有61.8％的肿块>5cm的患者符合指南，需要首选CT进行成像。与粘附性增加相关的因素包括较大的肿瘤大小（T1bvsT1a）和实体（与囊性或不确定）肿瘤（P<0.05）。在引入VBR之前，46.7％的患者接受了两种类型的影像学检查，相比之下，干预后为49.0%。在>5cm的肿块中，成像率仅略有增加（VBR前58.3％vs后61.2％，P=.56）和3-5厘米（VBR前50.0％vsVBR后56.2％，P=.0585）。
结论：在cT1肾脏肿块的初始评估期间，胸部成像指南的依从性是可以接受的，特别是考虑到大多数肿块<3cm，转移风险较低。然而,尽管主要泌尿外科学会对>4-5厘米的肿块成像达成了共识，整个音乐的成像率很低。在教育和VBR激励启动后，3-5厘米和>5厘米肿块的成像率仅略有变化。仍然存在显著的实践可变性和改进空间。
